Shock (circulatory)
Effects of inadequate perfusion on cell function
Click to expand
Compromised microcirculation
From: http://www.cvpharmacology.com/clinical
topics/hypotension.htm
Vasoconstrictive
Vasodilatative
Hypothermia
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Classification
1.
2.
3.
4.
Classification
Hypovolaemic
Hemorrhagic, Fluid
depletion, Increased
vascular capacitance
Cardiogenic
Myopathic,
Mechanical,
Arrhythmic
Distributive
Septic, etc.
Obstructive
PE, pericarditis,
pnumothorax etc.
Hypovolemic shock
Hypovolemic shock
This is the most common type of shock and
based on insufficient circulating volume.
Its primary cause is loss of fluid from the
circulation from either an internal or external
source.
An internal source may be haemorrhage.
External causes may include extensive
bleeding, high output fistulae or severe
burns.
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Cardiogenic shock
Cardiogenic shock
This type of shock is caused by the failure of
the heart to pump effectively.
This can be due to damage to the heart
muscle, most often from a large myocardial
infarction.
Other causes of cardiogenic shock include
arrhythmias, cardiomyopathy, congestive
heart failure (CHF), and cardiac valve
problems.
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Distributive shock
Distributive shock
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Obstructive shock
Obstructive shock
Endocrine shock
Vasoconstrictive
Hypovolamic
Cardiogenic
Vasodilatative
Circulatory
Septic
Cardiac
index
Cardiac
index
Peripheral
resistance
Peripheral
resistance
Blood
Volume
Blood
Volume
Malperfusion and organ dysfunction are the ultimate end point of any shock stage
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Decreased
myocardial
contraction
Inracellular
fluid
loss
BP = CO x SVR
Metabolic
acidosis
Cell hypoxia
Microcirculatory demage
Cellular aggregation
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Hypovolemic Shock
loss in circulatory volume
HYPOVOLEMIC (oligemic)
SHOCK
Hemorrhagic
- Trauma
Thermal injury
- Gastrointestinal
Trauma
- Retroperitoneal
Anaphylaxis
Increased vascular
capacitance (venodilatation)
- Sepsis
- Anaphylaxis
- Toxins/Drugs
Dehydration
Vomiting
Diarrhea
Polyuria
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Cardiogenic Shock
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CARDIOGENIC
Myopathic
-Cardiomyopathy
-Post ischemic
myocardial stunning
-Septic myocardial
depression
-Pharmacologic
Anthracycline
cardiotoxicity Calcium
channel blockers
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CARDIOGENIC (2)
Mechanical
-Valvular failure Regurgitant Obstructive
-Hypertropic cardiomyopathy
-Ventricular septal defect
Arrhythmic
-Bradycardia Sinus (e.g.,vagal
syncope)Atrioventricular blocks
-Tachycardia SupraventricularVentricular
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DISTRIBUTIVE
Anaphylactic, anaphylactoid
Endocrinologic
Adrenal crisis
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Symptoms
Narrowing of
pulse pressure
Tachycardia,
hypotension
Anxiety
Obtundation
Dyspnea
Unconsciousness
Restlessnes
Disphoria
Decreased urine
output
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Treatment of
shock
Generalities:
Positioning, avoiding
hypothermia
Maintaining adequate
oxygenization
Fluid resuscitation
Pain relief ?
(inotropic treatment?)
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Maintain Volume
-Fluid redistribution to
vascular space
From interstitium
(Starling effect)
From intracellular
space (Osmotic
effect)
Decreased
glomerular filtration
rate (GFR) Increased
aldosterone
Increased
vasopressin
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Mintain Pressure
Increased angiotensin
Increased vasopressin
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Increased contractility
Sympathetic stimulation
Adrenal stimulation
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Fluid resuscitation
IV line
Colloids
Dextrane
More iv line
Hydroethylstrach
Choice of infusion
Gelatine
Lactated Ringer's
solution (initial
bolus: 10-25 ml/kg
/ 10 min.)
Rate, amount
General conditions
parameters ( BP, Pulse,
CVP, SatO2 etc)
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Dextrane
Elimination:
metabolic
kidney
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Hydroxyethylstrach
Elimination:
kidney
Inotropic drugs
Inotropie
Heart rate
SVR
Epinephrin
++
Norepinephrin
++
++
Dopamin
++
Dobutamin
+++
Isoproterenol
++
Amrinon
+++
Cardiac
Output
Dose
10-30
mcg/min
--
2-8
mcg/min
++
++
2-5
mcg/min/kg
(+)
--
++
5-15
mcg/min/kg
++
++
5 mcg/mi
++
--
Kidney
Cornarry
Blood flow Blood flow
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Further Study:
Joynt, Gavin (April 2003). "Introduction to
management of shock for junior ICU trainees and
medical students". The Chinese University of
Hong Kong. Retrieved on 9 October, 2014.
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